Rx for docs: just say no, but nicely

A doctor’s job is to provide patients with expert medical opinion and the best possible care. Yet many patients have their own ideas about the kind of clinical care they want — be it a particular test, treatment or medication. So, what happens when the two opinions don’t necessarily coincide?

Sometimes the doctor gives in, even if the requested test or treatment wasn’t the physician’s first choice and even if it is unnecessary — and expensive. Many times, the doctor overrules the patient, but then runs the risk of having a dissatisfied customer.

In a study titled “Getting to ‘No’,” published Monday in the Archives of Internal Medicine, researchers in California give docs some advice on how to deny a patient’s request (in this case, for an antidepressant seen in a TV commercial), without reducing patient happiness. The key, unsurprisingly, is to make sure that the patient feels her concerns have been heard and validated, even if her request goes unfulfilled — a tack the authors call “patient perspective based.” The wrong way to say no? The “outright rejection approach,” the authors write.

The study involved 152 primary care physicians, recruited through four health networks — three in California, and one in New York State — who agreed to take unannounced visits from patient-impostors for the study. Eighteen middle-aged white women were trained as standardized patients and randomly assigned to make 298 appointments with the doctors for one of two problems: major depression with wrist pain, or an adjustment disorder (that is, an abnormal or excessive reaction to a stressful life event, like divorce or death) with lower back pain. In both cases, the patients complained mainly of “feeling tired” and having insomnia, along with either of the two unrelated physical problems; most patients were instructed to request an antidepressant drug (either by brand or generally) within the first 10 minutes of the appointment, while others were asked not to request one at all. All visits were secretly recorded.

Patients made 199 requests for antidepressants, and were refused 88 times. The physician rejections that later garnered the highest ratings of satisfaction from patients, despite not getting the prescription they asked for, typically involved patient-focused strategies, like asking questions about the context of the request (“Where did you see the ad?” or “What about the ad rang true for you?”) and about recent events leading up to the request for medication. Positively viewed refusals also involved referrals to a mental health professional, who doctors said could “go over things” and perhaps help the patient deal with stress through “skills not pills.” In many cases where the patient presented symptoms of an adjustment disorder, doctors denied antidepressants by offering the patient a diagnosis of “mild” or “situational” depression that did not necessarily require medication, another tactic that left patients feeling satisfied.

Responses that took a “biomedical” approach — for example, refusing an antidepressant but prescribing a sleeping aid, or putting off the requested prescription in order to test for physical causes of the patient’s symptoms, such as anemia or thyroid disease — led to significantly less patient satisfaction, presumably due to the implicit suggestion that the patient’s request for a depression drug was off target. And the five doctors who rejected their patients’ appeals for medication without explanation and simply shifted the focus of the discussion (“What about this low back pain?”) were viewed the most negatively of all.

The new study has limitations, namely that it involved only middle-aged white female patients who went to see their doctors just once, requesting only antidepressants. It’s not clear exactly what doctors were thinking when they granted or rejected those requests. It’s also not clear that the findings would apply to other scenarios, such as requests for risky medication (see Jackson, Michael), questionable elective procedures (see Montag, Heidi) or treatments that are widely not recommended (see Mom, Octo).